Controlling the system

Francis Spufford’s novelRed Plenty follows a cast of characters – economists, computer programmers, biologists, writers, fixers – around the Soviet Union of the 1950s and 1960s. This was time of optimism, when the planned economy would become, in Spufford’s phrase, ‘its own self-victualling tablecloth.’ One of those characters was Vasily Nemchinov, architect of the scheme to reform the Soviet economy mathematically. ‘Cybernetic’ institutes were established, mathematical and linear programming models were developed for balancing supply and demand over the short- and long- terms, for different economic sectors and on local, regional and national scales.

Of course, it proved an impossible task. Next year’s planning and purchasing decisions were being made on imperfect information at the same time as planners were still working on this year’s (massively complex) calculations. In 1964 it was predicted by some reformers that by 1980 the entire Soviet population would have had to work full-time on balancing supply and demand in the National Plan.

Tim Harford’s book Adapt tells a similar story about Project CyberSyn in Allende’s Chile in the early 1970s, where attempts were made to use computers to coordinate an increasingly nationalised economy, allowing for feedback and second-order effects. Decision-making was highly centralised, and the system succeeded only in reporting the problems that local factory managers wanted to report.

So what does this tell us about healthcare systems? Like the Soviet economy, modern health systems in developed countries are massively complex, with many interdependencies across different scales which evolve in response to policy and other levers. The need for ‘whole system thinking’ is often trotted out like a mantra, but what this means and how to deliver it is as unclear as ever. In the UK, the NHS is a system that is already fragmented and – arguably – fragmenting further. What is far less clear is finding the right levers to stimulate change or innovation, and knowing when and where to exert them.

Complexity theory can help us unpick the nature of interactions between the key elements of a health system and its potential to adapt and display ‘emergence’ – the way the interactions over time between the constituent elements make the whole different from the sum of its parts. This type of thinking takes an adaptive view of the world, where agents organise themselves into new relationships and behaviours, rather than a deterministic one in which deliberate strategy and processes of control result in change. Of course, these characteristics present problems for traditional approaches to management or policy development, which tend to rely on our ability to define a strategy that can be effectively communicated and then deliberately directed towards planned or predictable outcomes.